Provider Demographics
NPI:1073800595
Name:KOONTZ, KATELIN MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:KATELIN
Middle Name:MARIE
Last Name:KOONTZ
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KATELIN
Other - Middle Name:MARIE
Other - Last Name:LATTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:33900 HARPER AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-416-9100
Mailing Address - Fax:586-416-9103
Practice Address - Street 1:12174 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-4578
Practice Address - Country:US
Practice Address - Phone:317-610-0700
Practice Address - Fax:317-610-0702
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070018931225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist